History Taking Flashcards
when taking a history what are the 5 basic steps to take across the whole process
listen let the patient tell their story open questions closed/direct questions symptom specific questions
what types of history should you consider in a consultation
past medical history mental health history drug history family history social history personal history (sexual, holidays, work)
when someone presents you with a complaint what should you be asking or considering
symptoms - duration, associated symptoms, precipitating factors, relieving factors (coping)
impact - bio-psycho-social, on patient or others
what does ICE mean
ideas concerns and exceptions of symptoms and treatments
when asking about drug history what areas do you ask about
prescribed, compliance side effects or any allergies
smoking
alcohol
illegal drugs
what should you be aware about with allergies
ask how type of reaction they had to allergic reactions and whether it is recommended never to have again
in terms of a medical history what areas should you ask about
diabetes, stroke, IHD/MI, medically unexplained symptoms
past mental health issues
when asking about past mental health what points should you aim to cover
SHOULD BE PART OF EVERY HISTORY TAKING
past medical history
previous episodes or illness
previous diagnosis, treatment and by whom
types o mental illness, depression anxiety etc
suicide attempts or self harm
any current contact or help with mental illness
what are the many aspects that can be a part of social history
housing occupation typical day relationships medication mobility/driving hobbies services such as day care or home care pets visitors church or other religious areas
what is a personal history and give examples
how they have lived their life - how has their life led to these symptoms
early childhood and development relationsips schooling occupation relationships marriage children life events
when assessing pre-morbid personality what does CHASM mean
character hobbies attitudes stress response mood
what aspects of family history should you assess
mental disorders in the family
family relationship, parents siblings children
when assessing risk we seek to reduce harm to the patient - what are common risk factors to ask about
risk to self others children or staff
who what when where why
exacerbating factors or protective factors
asking about suicide does not make it more likely to happen
child protection
